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Predetermination patient responsibility

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Recently I came across two Medical Practices who determine patient responsibility (out of pocket expense and deductible) prior to service based on for what reason patient will be seen and they collect from patient in front. Is anyone aware of such a software which can give us pre estimate for patient deductible and out of pocket responsibility based on CPT code? Please share this information.

I am aware that if it is straight office visit then it will be fixed copay but it is hard to figure out the actual deductible or out of pocket expense on specific CPT.


Verification through the insurance co. If you use a clearing house see if they offer the service. Or some Co have automated services but remember pre-determination and even pre auths is never a guarantee that the claim will be paid.

Actually, there are plans that don't have a fixed co-pay for an office visit, instead it is a co-insurance amount.

As Merry replied, there are several ways to determine what a patient's benefits are ahead of time. There are also websites such as Navinet and Availity to figure it out. But in order to know what to charge the patient, you have to know what the fee schedule is for each payer, for each CPT code that is being billed. How do the offices know BEFORE the patient is being seen what the charges will be? I am thinking in particular about E/M codes 992XX...there is no way to know what level visit will be charged without seeing the patient first.

Also, some insurance contracts with providers prohibit them from collecting money up-front from patients(other than co-pays), so be careful with this.


--- Quote --- Is anyone aware of such a software which can give us pre estimate for patient deductible and out of pocket responsibility based on CPT code?
--- End quote ---

Wow, I'd buy it. LOL  seriously.. no software can do this. you might be thinking of a pre-determination of benefits and I have seen software that will put one out for you. It's a form that goes the insurance carrier (usually only on high dollar claims) before the services are rendered with the  physician's fee and the carrier will tell you yes or no it's within R&C and some will give you the deductible, coinsurance and any copay. Like I said these are really only used for high dollar surgical claims where you know the procedure ahead of time and want to find out if it's within U&C.

Others mentioned the clearinghouses and services.. I do my own via phone.. I have timed this process and I think it takes longer sometimes, so I stick with the good ol fashioned phone.

Thanks for reply and I do agree with all of you, but it happened with me recently. I went to one of the specialist for first time. While making the appointment they asked me why I want to see XYZ specialist and I gave the information about my condition. When I went for my appointment I was given XYZ software's pad to enter all the information and at the end it asked me the payment of xxx amt as my responsibility for service. It was not a fixed copay. I was surprised and asked to frond desk rep that how did they figured out that what level of services will be billed to insurance without even seeing the doctor. She said based on the problems I told over the phone at time of appointment, Dr. has predetermined the level of services. As a Biller I am aware that except copay, it is not legal to collect from patient prior to services so I called my insurance after the service and advised them that Physician collected in front. Insurance rep advised that Physician's are allowed to do so. I was very surprised to hear that.

So, I thought to share this with other billers as we all work hard to collect from patients after insurance process the claim. I have contacted my clearing house to see if they carry any product to predetermine the patient responsibility.


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